FORNESS CONTRUCTION, INC.)-2017 - Laserfiche WebLink

Home Browse Search

ACOR& CERTIFICATE OF LIABILITY INSURANCE DATEY) 4/3/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Customer Service Department Target Insurance Services 6630 Flanders Drive PHONE (800)450-8013 FAx (A/C, No, Ext): (A/C, No): (866) 227-3052 xCert ADDRESS, Certificates@tgfis.com INSURER(S) AFFORDING COVERAGE _ _ NAIC # San Diego CA 92121 INSURER AAssociated Industries Ins Co Inc 23140 INSURED INSURERB:United Financial Casualty Co 11770 INSURER C: Forness Construction Inc 1141 Rosemary Circle INSURERD: INSURER E : Corona CA 92879 1 INSURERF: COVERAGES CERTIFICATE NUMBER:GL/BA 17-18 REVISION NUMBER - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL D SUBR D POLICY NUMBER POLICY EFF MMIDD/YYYY POLICY EXP MM1L-1C- YY LIMITS A X I COMMERCIAL GENERAL LIABILITY CLAIMS -MADE �X OCCUR EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 X AES102591603 12/16/2017 12/16/2018 PERSONAL & ADV INJURY $ 1,000,000 _ GENERAL AGGREGATE $ 2,000,000 GEN'L I AGGREGATE LIMIT APPLIES PER: POLICY "" I JERCOT- D LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ B ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS 01931135-5 11/6/2017 11/6/2018 BODILY INJURY (Peraccident ) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ Uninsured/Underinsured $ 1,000,000 UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LAB CLAIMS -MADE DIED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A STATUTE I iER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The City of Santa Ana, it's officers, employees, agents and representatives are named as Additional Insured; Primary Non-Contibutory Wording applies, per the attached Endorsement(s). Certificate Holder Reference: On -Call Agreements A-2017-220 *Additional Insured status is subject to all policy terms, exclusions and conditions* REVIEWED BY: EUNICE HEREDIA (PG/ OF ) L'3WIN tial"ilL7ilVE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Public Works Agency ACCORDANCE WITH THE POLICY PROVISIONS. Leticia Lopez 20 Civic Center Plaza, M-36 AUTHORIZED REPRESENTATIVE Santa Ana, CA 92701 e H *Account Carl/MSTEV U 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025onunii